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Singapore Flap (Pudendal Thigh Fasciocutaneous Flap)

The Singapore flap, also called the pudendal thigh fasciocutaneous flap (PTF), is a sensate pudendal-thigh fasciocutaneous flap centered on the groin crease just lateral to the labia majora; its posterior labial arterial supply derives from the perineal branch of the internal pudendal artery. Described by Wee and Joseph in 1989 for vaginal reconstruction, it has reported applications in bilateral neovaginal construction, complex perineal fistula repair, vulvar reconstruction and burn-contracture release.[1][2] In Monstrey's selected 2001 series all 31 flaps survived completely.[1][2]

Singapore versus lotus petal. The "Singapore flap" name is sometimes also applied to the gluteal-fold lotus petal flap (Yii and Niranjan 1996). The donor sites and primary indications differ: the Wee–Joseph groin-crease or upper medial thigh flap on this page is used for bilateral neovagina and posterior vaginal reconstruction, while the gluteal-fold IPA-perforator lotus petal flap is used for vulvar oncologic reconstruction, ELAPE pelvic-floor coverage, and male perineal or scrotal reconstruction.

Nomenclature​

The same flap appears in the literature under several names reflecting anatomical basis and design variations:

NameOrigin / framing
Singapore flapWee & Joseph described the neurovascular pudendal-thigh flap at Singapore General Hospital in 1989[2]
Pudendal thigh fasciocutaneous (PTF) flapDescriptive anatomical name
Internal pudendal artery perforator (IPAP) flapModern perforator-based nomenclature (Yii & Niranjan 1996) — refines the design around explicitly identified perforators[3]
Lotus petal flapWhen the cumulative perineal flap designs from gluteal fold to genitocrural sulcus resemble lotus petals — see the dedicated lotus petal page for the gluteal-fold variant[4]
Gluteal-fold flapWhen the lower (gluteal-fold) "petal" is used — donor scar hidden in the gluteal fold

These terms are sometimes used interchangeably.

Vascular Anatomy​

The Singapore flap is a three-vascular-territory fasciocutaneous flap with its pedicle situated close to the midline. Tham and colleagues (2010) analyzed pudendal-thigh-flap vascular anatomy using lead-oxide injection in 5 cadavers.[5]

Sequential blood supply to the pelvic-floor integument (medial to lateral):

  1. Posterior labial and posterior scrotal arteries. Terminal branches of the internal pudendal artery; located deep to Colles' fascia; the primary pedicle of the Singapore flap.
  2. Cutaneous branches of the anterior branch of the obturator artery. superficial to Colles' fascia; supply the middle territory.
  3. Branches of the external pudendal arteries. superficial to Colles' fascia; supply the lateral or distal territory.

All three vascular territories run close to the midline, medial to the originally described PTF design. Two clinical implications follow directly:

  • Tham and colleagues proposed considering a more medial design than the original description to capture these territories; adapt it to the patient's vessels and available tissue.
  • The distal (lateral) third of the flap is fed by the most precarious territory (external pudendal branches), explaining the well-documented problem of apical necrosis in larger flaps.[5][6]

Related perforator anatomy. Giroux 2021 used color Doppler in 15 subjects, identifying 24 perforators overall and a mean internal-pudendal perforator distance of 27.3 mm from the ischial tuberosity.[3]

A microdissection study (Jin 2009) identified 4 relatively constant perforators in the perineum (inguinal and perineal branches of the superficial external pudendal artery, an anterior-obturator perforator, and a perforator from the lateral branch of the posterior scrotal (pudendal) artery) forming upper, middle, and lower vascular anastomoses in the deep fascia above the adductor wall.[7]

Sensory innervation. Cutaneous branches of the ilioinguinal, genitofemoral, posterior labial, and posterior femoral cutaneous (rami perineales) nerves lie within the flap territory, making the flap sensate, which is an advantage for functional reconstruction.[7]

Applications in GU and Urogynecologic Reconstruction​

1. Neovagina — congenital vaginal agenesis (MRKH / Müllerian agenesis)​

Congenital vaginal agenesis is the original and most extensively described PTF indication. A 2024 systematic review found primary vaginal dilation to be a viable initial treatment for MRKH syndrome.[28] Bilateral PTF flaps are transposed medially and sutured together to create a skin-lined vaginal pouch.

  • Monstrey 2001. 8 patients with congenital atresia; all 16 flaps survived completely; functional outcome rated excellent by the authors; no stents or dilators required; sensate reconstruction.[1]
  • Ajmal and Yusuf 2010. In 19 patients with vaginal atresia (11 MRKH, 8 isolated atresia), all 38 flaps survived at a mean 1-year follow-up. Two patients had neovaginal infection, two had donor-site dehiscence, and hair growth bothered 8/19.[29]
  • Selvaggi 2003. 2 patients with vaginal aplasia and functioning uterus; bilateral PTF with laparotomy for uterovaginal continuity; normal menstruation restored in both; coital satisfaction achieved. Sebaceous secretion and hair growth (manageable with laser depilation) were reported. One patient developed a granulation polyp and the other anastomotic stenosis; both were managed. Menstrual outflow persisted at 13 and 33 months of follow-up.[8]
  • Selçuk 2013. In six patients with Müllerian agenesis, preoperative liposuction thinned the PTF; all had adequate vaginal depth at a mean 13-month follow-up. One flap had partial distal loss and healed after debridement and local care.[9]
  • Uccella 2024. Video report of a modification using internal-thigh fasciocutaneous flaps (12 × 5 cm) tunneled to a neovagina introitus in one 18-year-old patient (two cases performed to date); the neovagina was sensate and patent at 2 years and the external genitalia were preserved. The hospital stay lasted 16 days to allow proper vaginal dilator use; daily use initially, followed by intermittent use, was planned.[10]

Advantages over other neovagina techniques:

FeatureSingapore (PTF)McIndoe (skin graft)Bowel (sigmoid)Vecchietti / dilators
SensateYesNoNoVariable
Stents / dilatorsNot needed in Monstrey's selected series; needed after some postradiation stenosis repairsOften used, regimen variesDepends on technique and follow-upDilation is integral to nonsurgical treatment
Abdominal surgery requiredNoNoYesVecchietti: laparoscopic surgery; primary dilation: no surgery[31]
Natural vaginal angleYesVariableYesVariable
SecretionSebaceousDryMucus (excessive)Dry
Hair growthYes (manageable)NoNoNo
Donor-site morbidityGroin scar; sitting pain in 5/35 for <3 months and 1/35 for >3 months in one reviewed series[11]Thigh / buttock graft siteAbdominalNone
ComplexityLowLowHighLow

2. Neovagina — after oncologic resection (radical vaginectomy / pelvic exenteration)​

  • Monstrey 2001. 5 patients had bilateral flaps for vaginal reconstruction after oncological resection; all flaps survived and the authors rated the functional outcome excellent.[1]
  • Gleeson 1994. At 5–19 months, eight patients (six exenteration, two radical vaginectomy) had partial apical necrosis in four cases and complete bilateral necrosis in one; the latter was followed by an enterovaginal fistula. A separate patient developed a rectovaginal fistula at the rectal reanastomosis despite viable flaps. No patient with bilateral flaps or prior pelvic irradiation reported successful coitus. Vulvar pain, chronic discharge, hair growth and flap protrusion were also reported.[6]

These small, differently selected series show that prior radiation and the donor and recipient vascular field deserve careful planning. Tissue outside the irradiated field, including gracilis or VRAM designs, may be considered for substantial defects.[11][6]

3. Pediatric genital reconstruction​

Joseph 1997 reported the largest pediatric PTF series: 12 patients with bilateral flaps based on the posterior labial artery: 6 with congenital adrenal hyperplasia (CAH), 3 with vaginal atresia, 2 with cloacal deformities, 1 with testicular feminizing syndrome. Technique was simple and reliable with satisfactory functional and cosmetic results, performable as one-stage or staged reconstruction and combinable with correction of associated anomalies.[12]

4. Rectovaginal fistula (RVF) repair​

The PTF has been described for complex or recurrent RVF as a unilateral flap providing epithelial coverage and vascularized interposition; a de-epithelialized interposition variant has also been reported.[30]

  • Sauseng 2022. In a retrospective series of seven recurrent or complex type I/IIa fistulas, a de-epithelialized PTF was interposed after separate closure of the rectal and vaginal openings. Six of seven patients had complete fistula healing; one recurred at 3 weeks and was later found to have Crohn disease. Follow-up ended by 31 months, with two patients lost to follow-up.[30]

  • Monstrey 2001: 4 patients with recurrent or complex RVF, all flaps survived, and the authors rated the functional outcome excellent.[1]

  • Lee & Lee 2009: transverse Singapore flap for a 3 × 3 cm congenital RVF in an 18-month-old infant, simultaneously reconstructing posterior vaginal and anterior rectal walls; functionally and cosmetically satisfactory at 20-month follow-up.[13]

5. Posterior urethral defects in scarred perineum​

Monstrey 2001 used the Singapore flap in 2 patients with posterior urethral defects in heavily scarred perineums where local tissue was insufficient, providing well-vascularized, sensate tissue to a hostile wound bed.[1]

6. Obstetric fistula repair (low-resource settings)​

The Singapore flap has emerged as a particularly valuable adjunct in obstetric fistula surgery in low- and middle-income countries, where vaginal stenosis frequently complicates fistula repair.[14][15] Browning and colleagues proposed that augmenting scarred vaginal tissue might improve urethral closure by restoring elasticity.[14][15]

  • Pope 2018 (Malawi). Described the technique for vaginal reconstruction in women with vaginal stenosis and obstetric fistula. The authors describe the flap as reliable, safe, easy to dissect and requiring few supplies, which suits low-resource settings.[14]
  • Browning 2018. Singapore skin flap used prophylactically with Goh type 4 fistula (n = 45): 46% dry against an expected 19%. In patients with successful closure but persistent severe leakage (n = 24), 71% dry against an expected 26%. The authors' rationale is based on the integral theory, and the comparison is with expected rates rather than a control group.[15]
  • Pope 2020. Retrospective Malawi review of 69 patients (32 Singapore alone, 20 gracilis alone, 17 both); the authors noted a possible advantage of incorporating the gracilis flap even when the Singapore flap alone was thought sufficient.[16]
  • Maljaars 2022. Follow-up of 60 patients after obstetric fistula repair with vascularized flaps in Malawi: 62% successful closure, 12% full continence; no major complications; quality of life improved despite persistent incontinence.[17]

7. Vulvar oncologic reconstruction​

Appropriate for lateral or hemivulvectomy defects (unilateral) and total vulvectomy defects (bilateral):

  • Höckel and Dornhöfer describe pudendal-thigh flaps for lateral vulvar and planar partial vaginal defects; their algorithm favors bilateral pudendal-thigh flaps for distal circumferential vaginal defects and bowel flaps for total vaginal defects.[11]
  • Salgarello 2005 include the pedicled PTF in their algorithm for small-to-medium vulvar defects, alongside V-Y island and gluteal-fold flaps.[18]
  • Han 2023. 47 patients; 31 received internal pudendal artery perforator (IPAP) flaps and 16 PAP or TUG flaps. IPAP flaps had fewer wound complications (12.9% versus 37.5%, p = 0.04) in this selected cohort. It studied a related perforator design, not a head-to-head trial of the Wee–Joseph axial Singapore flap.[19]
  • Toulouse Algorithm (Ricotta 2025) proposes perforator flaps (including internal-pudendal-perforator) as first-line for vulvar reconstruction, tailored to defect location and size.[20] A 2024 systematic review found no statistically significant difference in pooled short-term complications between perforator and non-perforator vulvoperineal reconstructions.[27]

8. Vaginal stenosis (post-radiation)​

Clifton 2017 described the Singapore flap in one patient with post-radiation vaginal stenosis that recurred after conservative management and a prior gracilis flap. The flap provides sensate tissue, but ongoing vaginal dilation is imperative; stenosis can recur.[21]

9. Perineal burn-contracture release​

Benito 2012 described the PTF designed as a Y-V advancement for perineal burn contractures, exploiting its thinness, adaptability, and maintained sensitivity.[22]

10. Fournier's gangrene reconstruction​

The Alammar 2026 review describes multiple flap types for Fournier's gangrene.[23]

Surgical Technique​

The technique as refined by Monstrey 2001:[1][2]

  1. Patient positioning. Lithotomy.
  2. Flap design. Skin island marked in the groin crease (labiocrural fold) just lateral to the hair-bearing labia majora, with the base at the perineal body. In Gleeson's eight-patient oncologic series, flap sizes ranged from 9 × 4 cm to 15 × 6 cm.[6]
  3. Incision and elevation. Lateral border incised first; flap elevated from lateral to medial in a subfascial plane including skin, subcutaneous tissue, deep thigh fascia, and the epimysium of the adductor muscles.[6]
  4. Pedicle preservation. Dissect medially until the posterior labial artery is identified entering from the medial aspect. The ischial tuberosity is the safe boundary of medial dissection.[3]
  5. Flap islanding. Raised as a peninsula flap (skin bridge maintained) or as a true island flap for greater mobility and rotational arc.[1]
  6. Transposition / inset:
    • Bilateral neovagina. Both flaps transposed to the midline and sutured together to form a skin-lined cul-de-sac opening at the introitus.[2]
    • Unilateral fistula repair. Single flap rotated into the defect for epithelial coverage, interposition or both.[1]
    • Vulvar reconstruction. Flap rotated or advanced into the vulvar defect.[11][18]
  7. Donor-site closure. Primary, with an inconspicuous scar hidden in the natural groin crease.[1][2]

Technical refinements​

ModificationDescriptionIndication
Liposuction thinning (Selçuk 2013)Two-stage: subcutaneous fat under the planned skin island thinned with liposuction 3 months before flap elevation — produces a thinner flap closer to native vaginal tissue[9]Müllerian agenesis with bulky thighs
Transverse design (Lee & Lee 2009)Transverse orientation to simultaneously reconstruct posterior vaginal and anterior rectal walls[13]Complex congenital RVF
Bilobed design (Ninomiya 2010)Combines gluteal-fold and pudendal-thigh flaps as a bilobed flap — depth + width with hidden donor scars[24]Large vulvar defects requiring vaginal depth
Prefabricated flap (Gürlek 2008)PTF prefabricated with a cervical canal for combined cervical + vaginal reconstruction; preserves uterus for potential pregnancy[25]MURCS syndrome
Y-V advancement (Benito 2012)PTF designed as Y-V advancement[22]Perineal burn-contracture release
IPAP perforator design (Han 2023)Perforator-based design with Doppler mapping; in a defect-location-selected retrospective cohort, wound complications occurred in 4/31 IPAP cases (12.9%) and 6/16 PAP or TUG cases (37.5%)[19]Vulvar oncologic reconstruction

Outcomes Summary​

IndicationSeries shown (n)Flap survivalFunctional outcomeKey complications
Neovagina — congenital agenesis8 (Monstrey 2001)100%[1]Excellent; sensate; no dilatorsHair growth; sebaceous secretion
Neovagina — after oncological resection5 (Monstrey 2001)100%[1]ExcellentWound dehiscence in 2 and minor introital correction in 2 across the 19-patient series
Neovagina — oncologic resection8 patients (Gleeson 1994; six exenteration, two radical vaginectomy)Four patients with partial apical and one with complete bilateral necrosisOne successful intercourse after unilateral flap in nonirradiated pelvisVulvar pain; discharge; protrusion; hair reported
Complex / recurrent RVF4 (Monstrey 2001)100%[1]ExcellentNot reported separately
Posterior urethral defect (scarred perineum)2 (Monstrey 2001)100%[1]ExcellentNot reported separately
Obstetric fistula (low-resource)60 (Maljaars 2022; Singapore flap and/or gracilis)Not reported separately62% self-reported closure; 12% full continence at follow-upSurgical complications in 37%, mostly minor wound breakdown; no major complications reported[17]
Pediatric genital anomalies12 (Joseph 1997)—Satisfactory—
Vulvar reconstruction (related IPAP design)31 internal pudendal artery perforator flaps in a 47-patient cohort (Han 2023)——12.9% wound complications with internal pudendal artery perforator flaps[19]
Perineal burn-contracture release1 (Benito 2012)Flap used successfullySatisfactoryNone reported

Complications and Limitations​

Flap-related

  • Apical (distal) necrosis. The most significant complication, particularly with larger flaps. Anatomically explained by the precarious blood supply of the distal third territory (external-pudendal branches). A delay procedure can mitigate this in large designs.[5][6]
  • Wound dehiscence. Some wound dehiscence occurred in 2 of the 19 patients in Monstrey's series, and surgical complications, mostly minor wound breakdown, occurred in 37% of Maljaars' obstetric fistula cohort.[1][17]
  • Introital stenosis or narrowing. May require minor revision at the introitus.[1]

Functional

  • Hair growth in flap skin is manageable with preoperative or postoperative (or both) laser depilation.[1][8][6]
  • Sebaceous secretion. Chronic vaginal discharge from sebaceous glands within the flap skin.[8][6]
  • Vulvar protrusion or bulging. Bulkier flap base versus labial flaps may cause vulvar bulging after subcutaneous rotation.[11][6]
  • Vulvar pain. Reported in some oncologic series.[6]
  • Recurrent vaginal stenosis. Particularly in irradiated patients; ongoing dilator regimen necessary.[21]

Limitation: previously irradiated tissue

Gleeson's eight-patient gynecologic oncology series had frequent partial or complete necrosis and limited sexual-function recovery; the sole reported successful intercourse was after unilateral reconstruction in a nonirradiated pelvis.[6] This experience warrants assessing prior radiation and vascularity. Consider an alternate donor outside a compromised field when appropriate.[11]

Comparison with Other Vulvovaginal / Perineal Flaps​

FeatureSingapore (PTF)MartiusGracilisVRAMALT
TissueFasciocutaneousFibroadipose (no skin)MyocutaneousMyocutaneousFasciocutaneous
Skin islandYesNoYesYesYes
SensateYesNoNoNoCan be designed as innervated[32]
BulkLow–moderateLowModerate–highHighModerate
Stents / dilatorsIndication-dependent; no in Monstrey's series, ongoing after postradiation stenosis repair[1][21]N/ACase-dependentCase-dependentCase-dependent
Donor-site morbidityGroin scar; sitting pain in 5/35 for <3 months and 1/35 for >3 months in one reviewed vulvar series[11]Very low (labial)Low (thigh)High (abdominal wall; hernia)Moderate (thigh)
Irradiated recipient performanceAssess donor/recipient field; Gleeson's small series had substantial morbidityAssess tissueAssess tissueAssess tissueAssess tissue
Best forNeovagina; partial vaginal defects; non-irradiated fistulasFistula interpositionComplex fistulas; large dead spaceExenteration; large defectsLarge defects; irradiated fields
Head-to-head wound outcomesNot established for these five designs in matched patients; Han's 12.9% IPAP result and the separate VRAM/gracilis proportional meta-analysis are not directly comparable[19][26]————

Technical Pearls​

  • Design more medially than the original description; the three vascular territories all run close to midline.[5]
  • Use the ischial tuberosity as the lateral landmark for medial dissection of the internal-pudendal perforator; in Giroux's Doppler study of 15 subjects, the mean perforator distance from the tuberosity was 27.3 mm.[3]
  • Preserve the documented axial vascular plane. Gleeson's described PTF elevation included deep fascia and adductor epimysium; do not transfer that exact plane uncritically to a distinct free-style IPAP perforator design.[6]
  • Perforator mapping. Giroux and colleagues located IPAP perforators with color Doppler in 15 subjects and concluded that routine ultrasound is not always required for that perforator design.[3]
  • Limit flap length when possible; consider a delay procedure when distal extension is unavoidable.[5]
  • Join the bilateral skin paddles with skin facing the new vaginal lumen for neovaginal construction.[2]
  • Irradiated donor tissue. Consider gracilis or VRAM raised outside the field.[6][11]
  • Plan hair-removal strategy preoperatively (laser depilation) for neovaginal applications.[8]
  • Postoperative dilator regimen is needed for long-term neovaginal patency in oncologic and post-radiation indications.[21]

Key Takeaways​

The Singapore or pudendal thigh fasciocutaneous flap provides sensate, skin-bearing tissue from a nearby donor. Monstrey's selected neovaginal series reported complete survival of 31 flaps and no stent or dilator requirement in its patients, but dilation and follow-up depend on indication: after postradiation stenosis repair, Clifton explicitly advises ongoing dilation.[1][21] Prior irradiation, donor vascularity, hair-bearing skin and vaginal-wall needs should guide selection. The related IPAP design is a distinct perforator approach.[3][19]

See Also​

References​

1. Monstrey S, Blondeel P, Van Landuyt K, et al. The versatility of the pudendal thigh fasciocutaneous flap used as an island flap. Plast Reconstr Surg. 2001;107(3):719–25. doi:10.1097/00006534-200103000-00011

2. Wee JT, Joseph VT. A new technique of vaginal reconstruction using neurovascular pudendal-thigh flaps: a preliminary report. Plast Reconstr Surg. 1989;83(4):701–9. doi:10.1097/00006534-198904000-00018

3. Giroux PA, Dast S, Assaf N, Lari A, Sinna R. Internal pudendal perforator artery flap harvesting without pre-operative imaging: reliability and approach. J Plast Reconstr Aesthet Surg. 2021;74(6):1355–1401. doi:10.1016/j.bjps.2020.12.017

4. Yii NW, Niranjan NS. Lotus petal flaps in vulvo-vaginal reconstruction. Br J Plast Surg. 1996;49(8):547–54. doi:10.1016/s0007-1226(96)90132-0

5. Tham NL, Pan WR, Rozen WM, et al. The pudendal thigh flap for vaginal reconstruction: optimising flap survival. J Plast Reconstr Aesthet Surg. 2010;63(5):826–31. doi:10.1016/j.bjps.2009.02.060

6. Gleeson NC, Baile W, Roberts WS, et al. Pudendal thigh fasciocutaneous flaps for vaginal reconstruction in gynecologic oncology. Gynecol Oncol. 1994;54(3):269–74. doi:10.1006/gyno.1994.1209

7. Jin B, Hasi W, Yang C, Song J. A microdissection study of perforating vessels in the perineum: implication in designing perforator flaps. Ann Plast Surg. 2009;63(6):665–9. doi:10.1097/SAP.0b013e3181999de3

8. Selvaggi G, Monstrey S, Depypere H, et al. Creation of a neovagina with use of a pudendal thigh fasciocutaneous flap and restoration of uterovaginal continuity. Fertil Steril. 2003;80(3):607–11. doi:10.1016/s0015-0282(03)00977-4

9. Selçuk CT, Evsen MS, Ozalp B, Durgun M. Reconstruction of vaginal agenesis with pudendal thigh flaps thinned with liposuction. J Plast Reconstr Aesthet Surg. 2013;66(9):e246–50. doi:10.1016/j.bjps.2013.04.006

10. Uccella S, Galli L, Vigato E, et al. New neovagina-creating technique on the basis of a fasciocutaneous flap for Müllerian agenesis. Fertil Steril. 2024;122(2):382–4. doi:10.1016/j.fertnstert.2024.03.022

11. Höckel M, Dornhöfer N. Vulvovaginal reconstruction for neoplastic disease. Lancet Oncol. 2008;9(6):559–68. doi:10.1016/S1470-2045(08)70147-5

12. Joseph VT. Pudendal-thigh flap vaginoplasty in the reconstruction of genital anomalies. J Pediatr Surg. 1997;32(1):62–5. doi:10.1016/s0022-3468(97)90095-6

13. Lee DT, Lee GK. Transverse Singapore flap for reconstruction of a congenital rectovaginal fistula in an 18-month-old infant. Ann Plast Surg. 2009;63(6):650–3. doi:10.1097/SAP.0b013e31819ae002

14. Pope RJ, Brown RH, Chipungu E, Hollier LH, Wilkinson JP. The use of Singapore flaps for vaginal reconstruction in women with vaginal stenosis with obstetric fistula: a surgical technique. BJOG. 2018;125(6):751–6. doi:10.1111/1471-0528.14952

15. Browning A, Williams G, Petros P. Skin flap vaginal augmentation helps prevent and cure post obstetric fistula repair urine leakage: a critical anatomical analysis. BJOG. 2018;125(6):745–9. doi:10.1111/1471-0528.14953

16. Pope R, Hollier PC, Brown RH, et al. A retrospective review to identify criteria for incorporating the Singapore flap and gracilis muscle flap into obstetric fistula repair. Int J Gynaecol Obstet. 2020;148 Suppl 1:37–41. doi:10.1002/ijgo.13038

17. Maljaars LP, Nundwe W, Roovers JWR, Pope RJ. Follow-up of obstetric fistula repair using Singapore fasciocutaneous flap and/or gracilis muscle flap. Neurourol Urodyn. 2022;41(1):246–54. doi:10.1002/nau.24805

18. Salgarello M, Farallo E, Barone-Adesi L, et al. Flap algorithm in vulvar reconstruction after radical, extensive vulvectomy. Ann Plast Surg. 2005;54(2):184–90. doi:10.1097/01.sap.0000141381.77762.07

19. Han WY, Kim Y, Han HH. A simplified algorithmic approach to vulvar reconstruction according to various types of vulvar defects. Ann Plast Surg. 2023;91(2):270–6. doi:10.1097/SAP.0000000000003597

20. Ricotta G, Russo SA, Ferron G, Meresse T, Martinez A. The Toulouse algorithm: vulvar cancer location-based reconstruction. Int J Gynecol Cancer. 2025;35(4):100065. doi:10.1016/j.ijgc.2024.100065

21. Clifton MM, Gurunluoglu R, Pizarro-Berdichevsky J, Baker T, Vasavada SP. Treatment of vaginal stenosis with fasciocutaneous Singapore flap. Int Urogynecol J. 2017;28(3):493–5. doi:10.1007/s00192-016-3156-8

22. Benito P, De Juan A, Cano M. The pudendal thigh flap as Y-V advanced flap for the release of perineum burns contractures. J Plast Reconstr Aesthet Surg. 2012;65(5):681–3. doi:10.1016/j.bjps.2011.09.039

23. Alammar A, Laing K, Somasundaram J, Wallace DL, Rogers AD. Flap reconstruction following Fournier's gangrene: a systematic review of techniques and outcomes. Burns. 2026;52(3):107888. doi:10.1016/j.burns.2026.107888

24. Ninomiya R, Kishi K, Imanishi N, Nakajima H, Nakajima T. Reconstruction of vulva using pudendal thigh gluteal fold bilobed flap. J Plast Reconstr Aesthet Surg. 2010;63(2):e130–2. doi:10.1016/j.bjps.2009.06.011

25. Gürlek A, Aslan SS, Firat C, Ozturk-Ersoz A, Burak F. Combined cervical and vaginal reconstruction with prefabricated pudendal thigh flap in a case with cervical and vaginal agenesis (MURCS syndrome): a new and original technique. Ann Plast Surg. 2008;61(1):88–93. doi:10.1097/SAP.0b013e31815799d7

26. Eseme EA, Scampa M, Viscardi JA, et al. Surgical outcomes of VRAM vs. gracilis flaps in vulvo-perineal reconstruction following oncologic resection: a proportional meta-analysis. Cancers. 2022;14(17):4300. doi:10.3390/cancers14174300

27. Wendelspiess S, Kouba L, Stoffel J, et al. "Perforator versus non-perforator flap-based vulvoperineal reconstruction-a systematic review and meta-analysis." Cancers (Basel). 2024;16(12):2213. doi:10.3390/cancers16122213

28. Baby A, Pallam MC, Hayter M. "Effectiveness of non-surgical interventions to improve health and well-being in women living with Mayer-Rokitansky-Kuster-Hauser syndrome: A systematic review." J Adv Nurs. 2024;80(6):2167–2201. doi:10.1111/jan.15976

29. Ajmal S, Yusuf K. "Vaginoplasty with bilateral islanded pudendal thigh flaps." J Ayub Med Coll Abbottabad. 2010;22(1):1–6. https://www.ayubmed.edu.pk/JAMC/PAST/22-1/Samira.pdf PMID:21409891

30. Sauseng S, Kresic J, Mayerhofer M, et al. "Surgical treatment of deep-lying ano-/rectovaginal fistulas using a de-epithelialized Singapore flap (pudendal thigh flap)." Eur Surg. 2022;54:136–143. doi:10.1007/s10353-022-00759-7

31. Committee on Adolescent Health Care. "ACOG Committee Opinion No. 728: Müllerian Agenesis: Diagnosis, Management, and Treatment." Obstet Gynecol. 2018;131(1):e35–e42. doi:10.1097/AOG.0000000000002458

32. Ribuffo D, Cigna E, Gargano F, Spalvieri C, Scuderi N. "The innervated anterolateral thigh flap: anatomical study and clinical implications." Plast Reconstr Surg. 2005;115(2):464–470. doi:10.1097/01.prs.0000149481.73952.f3